Gait Speed Is Associated with Cognitive Function among Older Adults with HIV

Abstract

Objectives: To determine links between objectively and subjectively measured physical function and cognitive function among HIV-positive older adults, a growing yet understudied group with elevated risk for multimorbidity. Methods: At a biomedical research visit, 162 participants completed objective tests of gait speed (4-m walk), grip strength (dynamometer), and cognitive function (Montreal Cognitive Assessment, MoCA) and reported their well-being (Medical Outcomes Study-HIV survey). Results: Those with faster gait speed had better overall cognitive function than those with slower gait speed (b = 3.98, SE = 1.30, p = .003) in an adjusted regression model controlling for age, sex, race, height, preferred language, and assistive device use. Grip strength was not significantly associated with overall cognitive function. Self-rated cognitive function was weakly related to MoCA scores (r = .26) and gait speed (r = .14) but was strongly associated with emotional well-being (r = .53). Discussion: These observed, expected connections between physical and cognitive function could inform intervention strategies to mitigate age-related declines for older adults with HIV.

Keywords

HIV chronic conditions physical function cognitive function well-being

Introduction

Older adults are a growing portion of people living with human immunodeficiency virus (HIV). According to recent Centers for Disease Control and Prevention (CDC) estimates, over 49% of Americans with HIV are now 50 years of age and older, and individuals aged 65 and older were the fastest growing HIV-positive demographic group from 2013 to 2017 (Center for Disease Control and Prevention, 2019). Despite high rates of viral suppression among those receiving HIV care (Bradley et al., 2016), people living with HIV (PLWH) experience elevated multimorbidity and aging-related syndromes that can compromise their quality of life as they age (Guaraldi et al., 2011). For example, older adults with HIV have elevated risk for cognitive impairment compared with their younger counterparts and those without HIV (Cohen et al., 2015). Accordingly, identifying and addressing modifiable factors that contribute to cognitive dysfunction is a key step in enhancing the health of older PLWH.

Prior work suggests links between physical function and cognitive health among people with HIV (Bourgeois et al., 2020; Erlandson et al., 2017), which may provide opportunities for interventions (Quigley et al., 2019) and aid in early identification of shared etiology (Eggers et al., 2017; Kallianpur et al., 2016). For example, physical activity may improve physical function and buffer against cognitive decline (Hillsdon et al., 2005). In a longitudinal study with variable follow-up visits, HIV-positive adults who reported higher levels of physical activity maintained higher levels of cognitive function over time compared with those who reported lower physical activity (Dufour et al., 2018).

The existing research examining physical function and cognitive function among those with HIV has primarily been conducted with middle-aged adults (Erlandson et al., 2017; Masters et al., 2019). However, the physical–cognitive connection is most relevant for older PLWH, given their greater likelihood for vulnerability in both areas. In addition, prior studies among PLWH often utilized self-reported measures of activity level or cognitive function (Dufour et al., 2018; Fazeli et al., 2015; Quigley et al., 2019). This is a limitation, as subjective and objective measures of cognitive and physical status often diverge (Crumley et al., 2014; Kapteyn et al., 2018). Objective markers of physical function (e.g., gait speed and grip strength) warrant further study, as they provide reliable measurement, can indicate readiness for physical activity, and may help to inform interventions.

To examine relationships between objective physical function indicators (gait speed and grip strength) and cognitive function, we utilized observational data from older adults with HIV who completed a biomedical assessment as part of a cohort study. We also examined the extent to which subjective measures of physical and cognitive function were related to objective assessments in order to inform research design and intervention targets for future work.

Methods

Participants

Older adults with HIV who were English or Spanish speaking were recruited from the HIV clinic at as part of a larger, multisite survey study using an age-stratified random selection strategy. Patients were invited to participate in this substudy, which included a biomedical assessment, if they were aged 55 or older and had documented HIV infection. Due to language capability of available staff, this substudy was conducted in English; thus, visits were only scheduled for those who indicated willingness and comfort to complete the study procedures in English. Those with complete data for gait speed and cognitive function measures were included in this analysis (n = 162). Informed consent was obtained, and the study procedures were approved by the Institutional Review Board.

Procedures and Measures

Participants attended a research visit at the Weill Cornell Clinical and Translational Science Center and completed biomedical assessments that were administered by trained research staff. Measures of physical function, cognitive function, and emotional health were administered at the visit, as summarized below.

Cognitive function

The Montreal Cognitive Assessment (MoCA) was administered and scored according to the test manual (Nasreddine et al., 2005). Total scores were used to index overall cognitive function. According to standardized methods, one point was added to scores for participants whose highest level of education was high school (12 years) or less. Domain scores for visuospatial/executive function, attention, naming, language, abstraction, delayed recall, and orientation were computed using the relevant subtests based upon prior work (Demeyere et al., 2016).

Physical function

Participants completed two 4-m walk trials at their usual speed (with assistive devices as needed), and gait speed was computed using the participant’s fastest trial time (Kallen et al., 2012; Margolick et al., 2017). Grip strength was measured using a dynamometer; participants completed three trials with their dominant hand, and the average of the trials was computed (Erlandson et al., 2017).

Subjective measures

Participants completed the Medical Outcomes Study-HIV (MOS-HIV) survey, a well-validated quality of life instrument (Wu et al., 1997). Subscale scores were computed for physical function, cognitive function, and mental health; internal consistency for each subscale was acceptable (Cronbach’s alpha = .86, .88, and .83, respectively). Higher scores indicate better self-reported well-being.

Statistical Analysis

Analyses were conducted in SPSS, version 24.0 (IBM Corp, Armonk, NY). Pearson correlations were used to evaluate bivariate associations between physical function (gait speed and grip strength) and total MoCA scores as continuous variables; relationships with subjective variables were also examined. In follow-up adjusted analyses, linear regression was used to examine links between gait speed and cognitive scores while controlling for age, sex, race, height, preferred language, and assistive device use. In exploratory analyses, bivariate associations between gait speed, grip strength, and MoCA subdomain scores were examined using Spearman rank correlations (rho). Because the interpretation of cognitive scores may be limited when conducted in a language other than the person’s preferred language, we also ran sensitivity analyses among only those whose preferred language was English (n = 148). These results are included in the Supplemental Material.

Results

Table 1 summarizes characteristics of the 162 participants. Participants were primarily Black (52%), middle-aged to older (M = 61.15, SD = 5.75), male (67%), and educated beyond high school (68%). The majority (93%) were virally suppressed, and 76% had been living with HIV for 20 or more years. 66% of the sample had gait speeds slower than 1 m/s, a cutoff from epidemiological literature indicating risk for subsequent negative health outcomes (Cesari et al., 2005).

Table 1.

Demographic and Key Variables for Sample (N = 162).

Characteristic	Mean (SD) or n (%)
Age (years)	61.15 (5.75)
Sex
Female	53 (33%)
Male	109 (67%)
Race
Black	82 (52%)
White	48 (30%)
Asian or Pacific Islander	2 (1%)
Bi- or multiracial	26 (17%)
Ethnicity
Hispanic/Latino	43 (30%)
Non-Hispanic/Latino	98 (70%)
Education level (years)
≤12	50 (32%)
>12	108 (68%)
Preferred language
English	148 (93%)
English or Spanish	3 (2%)
Spanish	7 (4%)
Other	2 (1%)
Viral load (copies/mL)
<200	150 (93%)
≥200	12 (7%)
Time since HIV diagnosis (years)	23.22 (5.79)
Gait speed (best trial, m/s)	.91 (.23)
Grip strength (average of 3 trials, kg)	31.90 (8.59)
MoCA score (total)	23.72 (3.46)

Note. % indicates percentage of those with available data for each variable. Data were missing for some participants for race (n = 4), ethnicity (n = 21), education (n = 4), preferred language (n = 2), and grip strength (n = 5). MoCA = Montreal Cognitive Assessment.

On the MoCA test, 35% of the sample scored lower than 23, indicating possible cognitive dysfunction (Carson et al., 2018). Among those whose preferred language was English only (n = 148), 34% scored below 23. MoCA scores were slightly higher though not significantly different for those who preferred English (M = 23.83, SD = 3.38) than those with another preferred language (M = 22.08, SD = 4.38; t(158) = −1.69, p =.09). In light of this pattern, we present primary analyses including all participants, and we present sensitivity analyses limited to those who preferred English (n = 148) in the Supplemental Material (Tables S1, S2 and S3), which revealed the same pattern as the primary results below.

Physical Function and Overall MoCA Scores

Bivariate analyses are summarized in Table 2. Those with faster gait speed had better overall cognitive function than those with slower gait speed (r = .23, p = .003). Grip strength was not significantly associated with overall cognitive function (r = .07, p = .38).

Table 2.

Bivariate Pearson Correlations between Objective and Subjective Variables.

	Objective Variable			Subjective Variable
	Gait Speed	Grip Strength	MoCA Total	Physical Function	Cognitive Function	Mental Health
Grip strength	.26**	—
MoCA total	.23**	.07	—
Subjective physical function	.42**	.20*	.14	—
Subjective cognitive function	.14	.04	.26**	.40**	—
Subjective mental health	.26**	.18*	.13	.42**	.53**	—

Note. * indicates p < .05, ** indicates p < .01. MoCA = Montreal Cognitive Assessment.

The association between faster gait speed and better MoCA scores remained statistically significant in the adjusted regression model, as detailed in Table 3 (b = 3.98, SE = 1.30, p = .003). The set of predictors explained 16% of the variance in MoCA scores (R² = .16, F(7,141) = 3.79, p = .001).

Table 3.

Adjusted Linear Regression Model with Gait Speed as a Predictor of Overall Cognitive Scores.

Predictor	Outcome: Total Montreal Cognitive Assessment Score
Predictor	b	SE	t	p
Age (years)	−.06	.05	−1.27	.21
Male sex	−.80	.64	−1.24	.22
White race	1.90	.59	3.25	.001
Height (cm)	.01	.02	.42	.67
Assistive device use	1.67	.93	1.80	.07
Preferred language (English)	1.15	1.11	1.04	.30
Gait speed (m/s)	3.98	1.30	3.07	.003

Relationships between Physical Function and MoCA Domains

Gait speed and grip strength were related to visuospatial/executive function domain scores (ρ = .17, p = .03 and ρ = .16, p = .04, respectively). As shown in Table 4, gait speed was also associated with attention and language domain scores. Links between gait speed, grip strength, and other domains of the MoCA were weaker and not statistically significant.

Table 4.

Bivariate Spearman Correlations (ρ) between Gait Speed, Grip Strength, and MoCA Domains by Subtest.

	MoCA Subtest
	Visuospatial/Executive Function	Attention	Naming	Language	Abstraction	Delayed recall	Orientation
Gait speed	.17*	.18*	.08	.21**	.02	.11	.04
Grip strength	.16*	.07	.10	.07	−.08	−.01	.09

Note. * indicates p < .05, ** indicates p < .01. MoCA = Montreal Cognitive Assessment.

Relationships between Objective and Subjective Measures of Physical and Cognitive Function

Self-rated physical function was moderately related to objective gait speed (r = .42, p < .001) and weakly related to grip strength (r = .20, p = .02). Self-rated cognitive function was only weakly related to objective MoCA scores (r = .26, p = .001), but was strongly associated with emotional well-being (r = .53, p < .001).

Discussion

In this cross-sectional analysis, HIV-positive older adults with faster gait speed had better overall cognitive function (as measured by the MoCA) than those with slower gait speed. Grip strength was not significantly related to overall cognitive scores. In exploratory analyses, better grip strength and gait speed were each related to higher executive function domain scores on the MoCA. These findings suggest links between objectively measured physical function and cognitive function among older adults with HIV.

These findings among older adults with HIV are consistent with the broader literature linking physical and cognitive health during aging. Physical frailty and cognitive impairment often co-occur among older adults without HIV (Grande et al., 2019a). Furthermore, in a meta-analysis of prospective studies, individuals with greater physical frailty were more likely to develop incident dementia than those who were less frail (Kojima et al., 2016). Gait speed and grip strength may be particularly robust indicators of frailty and cognitive decline (Peel et al., 2019). For example, slower gait speed as much as 7 years earlier and decreases in gait speed over time each predicted dementia risk (Dumurgier et al., 2017). In light of the broader literature, the current study underscores the value in examining these links among older adults with HIV, who are at elevated risk for cognitive decline compared to those without HIV (Cohen et al., 2015).

Future research is needed to determine whether interventions that promote physical function may have cognitive benefits (or vice versa) among older adults with HIV. Based on the robust links between gait speed, overall cognitive scores, and subdomains in this study, addressing modifiable factors contributing to gait speed may be particularly useful, while cognitive effects of improving grip strength may be more limited. In addition, most participants (66%) had gait speeds slower than 1 m/s, suggesting risk for poor health and functional impairment (Studenski et al., 2011). Accordingly, our results underscore the utility of integrating geriatric assessment into routine HIV care in order to identify needed supports and potential areas for interventions (Singh et al., 2017).

In addition, we observed that gait speed and grip strength were associated with cognitive scores for some domains but not for others. The most consistent link emerged between gait speed, grip strength, and performance on the visuospatial/executive function items, including trail-making, cube copy, and clock drawing tests. Performance on these tasks is heavily influenced by graphomotor ability and executive function (Lezak et al., 2004), which is associated with frontal lobe function (Miyake & Friedman, 2012). Similarly, studies in other populations suggest that physical activity and exercise exert positive effects on frontal lobe–mediated processes (Colcombe & Kramer, 2003; Northey et al., 2018; Stillman et al., 2019). For example, older adults who reported increasing their physical activity over time also showed increases in frontal-subcortical connectivity via task-free functional magnetic resonance imaging (Dorsman et al., 2020). Of note, the MoCA and other cognitive screening tools provide only limited assessment of domain-specific performance; thus, the initial domain-specific findings reported here warrant confirmation using in-depth neuropsychological test batteries to draw firmer conclusions about domain-specific results among HIV-positive older adults.

In this study, subjective cognitive function shared a stronger relationship with emotional well-being than with objectively measured cognitive function, consistent with research in other populations (Crumley et al., 2014). Reducing objective cognitive impairment will likely require different strategies compared to those that target subjective cognitive complaints. Because cognitive well-being includes both objective and subjective components, future studies of older PLWH may benefit from including both measures of cognitive function.

These results build upon prior studies that utilized self-reported physical activity assessments (Dufour et al., 2013, 2018; Fazeli et al., 2015) or studied middle-aged samples (Erlandson et al., 2017; Masters et al., 2019). By examining objective assessments of physical function in a broader sample of older adults with HIV, we observed similar, expected patterns with enhanced rigor and generalizability. The diversity of this sample is also a strength. However, MoCA administration was only available in English, a limitation. Although participants in this sample all reported English-speaking ability, some preferred other languages. This issue weakens the interpretation of cognitive scores for participants with preferred languages other than English. Importantly, the pattern of results held in the subset that preferred English (see Supplemental Material). Future research will be strengthened by inclusion of non-English-speaking participants and availability of bilingual or multilingual staff to facilitate best practices in administration in one’s preferred language.

Given the cross-sectional nature of this study, we were unable to test directionality of these effects, a primary limitation. For example, it may be useful to examine slower gait speed as an indicator of poorer cognitive function and/or risk factor for cognitive decline over time (Grande et al., 2019b). On the other hand, PLWH with neurocognitive impairment at baseline were more likely to develop slow gait during a 3-year study than those without neurocognitive impairment (Masters et al., 2019). Future studies should investigate longitudinal relationships between physical function and cognitive function among older adults with HIV, as these relationships may be bidirectional.

In summary, HIV-positive older adults with slower gait speed had poorer performance on objectively measured cognitive assessments than their faster counterparts in this cross-sectional study. Further investigating relationships between physical and cognitive function may lead to effective intervention strategies to mitigate age-related declines for this at-risk group.

Supplemental Material

RR_Supplementary_Material_2020_06_19 – Supplemental Material for Gait Speed Is Associated with Cognitive Function among Older Adults with HIV

Supplemental Material, RR_Supplementary_Material_2020_06_19 for Gait Speed Is Associated with Cognitive Function among Older Adults with HIV by Heather M. Derry, Carrie D. Johnston, Chelsie O. Burchett, Eugenia L. Siegler and Marshall J. Glesbyr in Journal of Aging and Health

Footnotes

Acknowledgments

The authors thank the participants in this study as well as the Weill Cornell Clinical and Translational Science Center staff.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Work on this study and manuscript were supported by grants from Gilead Sciences, the National Institute on Aging (T32 AG049666), the National Institute of Allergy and Infectious Diseases (T32 AI007613), and the National Center For Advancing Translational Sciences (UL1TR000457).

ORCID iDs

Heather M. Derry

Marshall J. Glesby

Supplemental Material

Supplemental material for this article is available online.

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